Labour , Delivery and
Postpartum Module اﳊلقه الثانيه
Episode 2
MRCOGPEARLS ORIGINAL SERIES
Mohammed Abdou
Saeed Hassan
MRCOG PEARLS
Mohammed Abdou
Saeed Hassan
Do not use the advice in this guideline to categorise antenatal CTG traces.
تلك المومنت لما تبقي شارح الجايدﻻين و مظبط الكوميكس بتاعته و
تيجي ال RCOGتغيره قبل اﻻمتحان
Indication of Continuous CTG
Antenatal risk factors
Antenatal maternal risk factors: Antenatal fetal risk factors
1. Previous caesarean birth or other full thickness uterine scar 1. Non-cephalic presentation (including breech,
transverse, oblique and cord), including while a
2. Any hypertensive disorder needing medication
decision is made about mode of birth
3. Pre-existing diabetes (type 1 or type 2) and gestational diabetes
2. Fetal growth restriction (estimated fetal weight below
requiring medication.
3rd centile)
4. Prolonged ruptured membranes (but women who are already in
3. Small for gestational age (estimated fetal weight below
established labour at 24 hours after their membranes ruptured do not
10th centile) with other high-risk features such as
need CTG unless there are other concerns)
abnormal doppler scan results, reduced liquor volume
5. Any vaginal blood loss other than a show or reduced growth velocity
6. Suspected chorioamnionitis or maternal sepsis 4. Advanced gestational age (more than 42+0 weeks at
the onset of established labour)
5. Anhydramnios or polyhydramnios
6. Reduced fetal movements before the onset of
contractions.
Indication of Continuous CTG
if any of the following factors are present at initial assessment or during labour
1. Maternal pulse > 120 b/min on 2 occasions 30 min apart 7. Confirmed delay in the first or second stage of labour
2. Temp 8. Contractions that
• ≥ 38°C : single reading • Hypertonus : last longer than 2 minutes
• ≥ 37.5°C or above on 2 consecutive occasions 1 hour apart • Tachysystole: ≥5 contractions in 10 minutes
3. BP: 9. Oxytocin use.
• Single reading: 10. Woman request
• systolic ≥160 mmhg or
11. Insertion of regional analgesia
• diastolic ≥ 110 mmhg, measured between contractions
• 2 consecutive : 30 minutes apart
• systolic ≥ 140 mmhg or
• diastolic ≥ 90 mmhg or more on, measured between
contractions
• A reading of 2+ of protein on urinalysis +
• single reading of either raised systolic blood pressure ≥ 140
mmhg
• diastolic blood pressure ≥ 90 mmhg
4. Pian differs from normal pain associated with contractions
5. Meconium Obtain an in-person review of every hourly assessment by
6. Fresh vaginal bleeding
another clinician ("fresh eyes") for women on CTG,
Medicolegal cases in CTG
®
CTG saving
MRCOG PEARLS
CTG advantage and disadvantage
• Neonatal seizures ®
• OVD & CS rates
• ± NICU admission & NMM
CTG machine
Telemetry
Switch from wireless to wired transducers ASAP if there is
signal loss which is not resolved by reducing the distance
between the base unit and the woman, in order to confirm
whether or not there is a clinical problem.
CTG interpterion
DR- C- BRVADO:
• DR: Define risk
• C: Contractions
• BR: Baseline rate
• V: Variability
• A: Accelerations
• D: Decelerations
• O: Overall impression
How to calculate time
DR- C- BRVADO
Contraction
• Rate
• Duration of contractions
Hypertonic Contraction: lasting more than 2 min
Tachysystole 5 or more in 10 min
1. Reducing or stopping oxytocin if it is being used
and/or
2. Tocolytic drug (subcutaneous terbutaline 0.25 mg).
Baseline Rate
• Normal range 110-160bpm
• Bradycardia <110
• Tachycardia >160 bpm
?
What is the Baseline Rate?
What is the Baseline Rate?
What is the Baseline Rate?
140 with acceleration ? How solve this Continue CTG
Or 160 with deceleration? problem?
Continue ?
What is the Baseline Rate?
What is the Baseline Rate?
What is the Baseline Rate?
Variability
• The presence of normal variability is
one of the best indicators of intact
integration between CNS and the
heart of the fetus
• Normal 5 to 25 bpm
What is the variability?
10-15
10-15
What is the variability?
>5
<5
What is the variability?
<5
Sinusoidal pattern ®
Sinusoidal pattern ® 2021
• Smooth undulating sine wave pattern
• Amplitude: 10 to 15 bpm
• Frequency: 3-5 cycles per minute
• Duration: >2 minutes
• Association with severe fetal anaemia
Accelerations
• FHR 15 bpm above the baseline / at least 15 seconds
• Associated with movement or stimulation
• Good indicator of fetal well-being and good reactivity
Decelerations
• Early : Head compression
• Late: U-P Insufficiency
• Variable : Cord compression - Primary CNS dysfunction
DR- C- BRVADO
A. Early deceleration
Head compression
DR- C- BRVADO
A. Early deceleration
DR- C- BRVADO
B. Late deceleration
U-P Insufficiency
DR- C- BRVADO
C. Variable deceleration
Cord compression - Primary CNS dysfunction
DR- C- BRVADO
Type of deceleration ?
DR- C- BRVADO
C. Variable deceleration
Without concerning characters With concerning characters
Variable decelerations with concerning characteristics
1. Reduced baseline variability within the deceleration
2. Failure to return to baseline
3. Biphasic (W) shape
4. No shouldering.
5. Lasting more than 60 sec
Variable decelerations with concerning characteristics
1. Reduced baseline variability within
the deceleration
2. Failure to return to baseline
3. Biphasic (W) shape
4. No shouldering.
Variable decelerations with concerning characteristics
1. Reduced baseline
1. Reduced variability
baseline within thewithin
variability deceleration
the deceleration
2. Failure to return to baseline
3. 2. No (W)
Biphasic shouldering.
shape
4. No shouldering.
5. Lasting more than 60 sec
Variable decelerations with concerning characteristics
1. Reduced
• Failurebaseline variability
to return within the deceleration
to baseline
2. Failure to return to baseline
3. Biphasic (W) shape
4. No shouldering.
5. Lasting more than 60 sec
Variable decelerations with concerning characteristics
1. Reduced baseline
• Biphasic variability within the deceleration
(W) shape
2. Failure to return to baseline
3. Biphasic (W) shape
4. No shouldering.
5. Lasting more than 60 sec
Let’s go back to the guideline
Features (White – Amber - Red)
Categorization (NSP)
Action
CTG features
RNA X
CTG features
1. Contraction
White: fewer than 5 contractions in 10 minutes
• White
• Amber :
• 5 or more contractions in 10 minutes, leading to reduced resting time
between contractions, or
• Hypertonus : longer than 2 minutes
CTG features
2. Accelerations
• The presence of fetal heart rate accelerations, even with reduced
variability, is generally a sign that the baby is healthy
• The absence of accelerations on an otherwise normal CTG trace does
not indicate fetal acidosis.
CTG features
1. Baseline FHR Amber
Increase in baseline fetal heart rate of 20
beats a minute or more from the start of
labour or since the last review an hour ago
<100 100-109 110-160 >160
Red Amber White Red
NB: If FHR 100-109 non reassuring but if normal variability and no variable or
late deceleration continue with usual care
CTG features
2. Variability
< 5 for more < 5 for to > 25 to 10 > 25 more
than 50 min 50 min
5-25 min than 10 min
RED Amber white Amber Red
If there is an absence of variability, carry out a review of the
whole clinical picture with a low threshold for expedited birth, as
this is a very concerning feature.
CTG features
3. Decelerations
Decelerations
Early Variable Late
• White
• Amber
White • Amber
• Red
• Red
Variable decelerations
½/½
With no concerning characterise With concerning characterise
Repetitive + < 30 Repetitive + > 30
> 30 min
minutes minutes
White Amber Amber Red
Repetitive = >50% of contractions
Late Decelerations
½/½
Repetitive + less than 30 minutes Repetitive + More than 30 minutes
Amber Red
2. Categorization (NSP)
Category Features
Normal No amber or red
1 Amber
Suspicious
1 red
Pathological OR
2 amber
• Continue CTG (unless it + No other concerning + other concerning risk factors
was started because of risk factors (as slow progress, sepsis or
concerns arising from meconium)
intermittent auscultation
and there are no ongoing Perform a full risk assessment
antenatal or intrapartum Perform a full risk assessment
risk factors) and usual care
• Continue to perform a full If accelerations are present =
risk assessment at least fetal acidosis is unlikely
Treat underlying cause
hourly and document the
conservative measures
findings Treat underlying cause
conservative measures Urgent review
(obstetrician or senior
midwife )
Fetal scalp stimulation Expediting birth
Urgent review (obstetrician or senior midwife )
Perform a full risk assessment
Exclude acute events (for example, cord prolapse, suspected placental abruption or suspected uterine rupture)
Conservative measures
Still pathological after conservative measures:
Further urgent review
Expediting birth
Fetal scalp stimulation
• If the CTG trace is suspicious with antenatal or intrapartum risk factors for fetal compromise, then
consider digital fetal scalp stimulation. If this leads to an acceleration in fetal heart rate and a
sustained improvement in the CTG trace, continue to monitor the fetal heart rate and clinical
picture.
• Be aware that the absence of an acceleration in response to fetal scalp stimulation is a worrying
sign that fetal compromise may be present, and that expedited birth may be necessary.
Intra-uterine resuscitation
DO (PHC)
1. Encourage mobilization (Change of maternal position) :
• 15° lateral tilt can cardiac output by 20-25% and stroke volume by 25-30%, and heart rate by 5-6 bpm or
• Encourage mobilization.
2. Hydration :
• IV fluid improves fetal oxygenation in cases of maternal hypovolaemia/hypotension.
• Don't use IV hypertonic dextrose.
3. of uterine contraction:
• Reduce or Stop: oxytocin
• Tocolysis (terbutaline 0.25 mg S.C)
DO NOT
1. Use of oxygen : but it can be used for maternal indications such as hypoxia or as part of preoxygenation before a potential anaesthetic.
2. Amnioinfusion
Fetal blood sample
Not available
Available Fetal blood sample Or
Contraindication
Result Expediting the birth
normal borderline: abnormal:
PH: ≥7.25 PH: 7.21 to 7.24 PH: 7.20 or below
Lactate: ≤ 4.1 mmol/l Lactate : 4.2 to 4.8 mmol Lactate : ≥ 4.9 mmol/l
PH Lactate
Normal ≥ 7.25 ≤ 4.1 mmol/l
Repeat FBS no more Deliver
Repeat FBS no more than borderline 7.21 to 7.24 4.2 to 4.8
than 30 minutes later if
one hour later if this is
this is still indicated by
still indicated by the CTG
the CTG Abnormal ≤ 7.20 ≥4.9 mmol/l
Fetal blood sample
How many FBS samples
Third sample Fourth sample
First sample Second sample
consultant decision NEVER
أمين معاك يا برنس
أسال الكبير أوعى
Fetal blood sample
Contra-indication of FBS (TAB – PMS)
1. Acute event : eg : cord prolapse, suspected placental abruption or suspected uterine rupture
2. Birth should be expedited
3. Risk of fetal bleeding disorders
4. Risk of maternal-to-fetal transmission of infection :
A. Active herpes
B. HIV
C. HBV, HCV
5. Malpresentation ( face ) what about breech ?? جرح الوش مفيهوش معلش
6. Premature < 34 W
7. Sepsis ??
Sepsis or significant meconium, FBS results may be falsely reassuring
Pathological CTG – Summary
Acceleration
Pathological Conservative FSS
CTG measures
NO
Acceleration
Not available or
Result FBS Contraindicated
Review the previous slide
Urgent
delivery
Acute bradycardia or a single prolonged deceleration for ≥ 3 minutes
CALL for help
• Correct any underlying causes(as hypotension
Prepare the woman •
or uterine hyperstimulation
Start 1 or more conservative measures
Prepare for Delivery (OVD-CS)
Deliver the baby ( baby out)
Let’s Practice
Late
Late
Late Decelerations
½/½
Repetitive + less than 30 minutes Repetitive + More than 30 minutes
Amber Red
• Continue CTG (unless it + No other concerning + other concerning risk factors
was started because of risk factors (as slow progress, sepsis or
concerns arising from meconium)
intermittent auscultation
and there are no ongoing Perform a full risk assessment
antenatal or intrapartum Perform a full risk assessment
risk factors) and usual care
• Continue to perform a full If accelerations are present =
risk assessment at least fetal acidosis is unlikely
Treat underlying cause
hourly and document the
conservative measures
findings Treat underlying cause
conservative measures Urgent review
(obstetrician or senior
midwife )
Fetal scalp stimulation Expediting birth
Urgent review (obstetrician or senior midwife )
Perform a full risk assessment
Exclude acute events (for example, cord prolapse, suspected placental abruption or suspected uterine rupture)
Conservative measures
Still pathological after conservative measures:
Further urgent review
Expediting birth
Prolonged brady
Acute bradycardia or a single prolonged deceleration for 3
minutes or more
CALL for help
• Correct any underlying causes(as hypotension
Prepare the woman •
or uterine hyperstimulation
Start 1 or more conservative measures
Prepare for Delivery (OVD-CS)
Deliver the baby ( baby out)
Normal
CTG features
1. Baseline FHR Amber
Increase in baseline fetal heart rate of 20
beats a minute or more from the start of
labour or since the last review an hour ago
<100 100-109 110-160 >160
Red Amber White Red
NB: If FHR 100-109 non reassuring but if normal variability and no variable or
late deceleration continue with usual care
Normal
110
Normal
Tachy
CTG features
1. Baseline FHR Amber
Increase in baseline fetal heart rate of 20
beats a minute or more from the start of
labour or since the last review an hour ago
<100 100-109 110-160 >160
Red Amber White Red
NB: If FHR 100-109 non reassuring but if normal variability and no variable or
late deceleration continue with usual care
170
Tachy
Tachy
Normal
Absent variability
Decrease variability
CTG features
2. Variability
< 5 for more < 5 for to > 25 to 10 > 25 more
than 50 min 50 min
5-25 min than 10 min
RED Amber white Amber Red
If there is an absence of variability, carry out a review of the
whole clinical picture with a low threshold for expedited birth, as
this is a very concerning feature.
Sinusoidal pattern
Sinusoidal pattern ®
Sinusoidal pattern ® 2021
• Smooth undulating sine wave pattern
• Amplitude: 10 to 15 bpm
• Frequency: 3-5 cycles per minute
• Duration: >2 minutes
• Association with severe fetal anaemia
Normal
Normal
Early dec.
Early dec.
Normal
Normal
Late
Late
Late
Late
Variable
Variable
Variable decelerations
½/½
With no concerning characterise With concerning characterise
Repetitive + < 30 Repetitive + > 30
> 30 min
minutes minutes
White Amber Amber Red
Repetitive = >50% of contractions
Variable
Variable
Variable decelerations
½/½
With no concerning characterise With concerning characterise
Repetitive + < 30 Repetitive + > 30
> 30 min
minutes minutes
White Amber Amber Red
Repetitive = >50% of contractions
Variable
Variable
Vaiable
Variable
• 1 Baseline initially 160bpm rising to 180bpm
• 2 Variability less than 5 beats
• 3 Atypical variable decelerations, loss of shouldering
• 1 Baseline 145–150bpm
• 2 Variability absent
• 3 Variable decelerations
• Baseline 180bpm
• Variability appears to be virtually absent
• Shallow variable decelerations
online-pdf-no-copy.com
